Louisiana Medical Power of Attorney Template
This Medical Power of Attorney is created in accordance with the laws of the State of Louisiana. It allows you to designate someone to make medical decisions on your behalf in the event that you are unable to do so.
Principal Information:
- Name: ________________________________________
- Address: ______________________________________
- City, State, Zip: ______________________________
- Date of Birth: ________________________________
Agent Information:
- Name: ________________________________________
- Address: ______________________________________
- City, State, Zip: ______________________________
- Phone Number: ________________________________
Alternate Agent Information:
- Name: ________________________________________
- Address: ______________________________________
- City, State, Zip: ______________________________
- Phone Number: ________________________________
Effective Date: This Medical Power of Attorney will become effective upon my incapacity, as determined by my attending physician.
Scope of Authority: My agent shall have the authority to make decisions regarding my medical care, including but not limited to:
- Consent to or refuse medical treatment.
- Access my medical records.
- Make decisions about life-sustaining treatments.
- Choose healthcare providers.
Signature:
By signing below, I affirm that I am of sound mind and voluntarily appoint the above-named agent to act on my behalf regarding medical decisions.
Principal's Signature: ___________________________
Date: ________________________________________
Witnesses:
This document must be signed in the presence of two witnesses who are not related to the principal or the agent.
- Witness 1 Name: _______________________________
- Witness 1 Signature: __________________________
- Date: ________________________________________
- Witness 2 Name: _______________________________
- Witness 2 Signature: __________________________
- Date: ________________________________________
Notary Public:
This document may also be notarized to enhance its validity.
Notary Signature: ________________________________
Date: ________________________________________